Prevalence of malocclusion and occlusal

traits in the early mixed dentition in

Shanghai, China
Xin Yu1 ,2 ,* , Hao Zhang2 ,3 ,* , Liangyan Sun2 ,4 , Jie Pan2 ,4 , Yuehua Liu2 ,4 and
Li Chen2 ,4 ,5
1
Department of Pediatric Dentistry, Shanghai Stomatological Hospital, Fudan University, Shanghai, China
2
Oral Biomedical Engineering Laboratory, Shanghai Stomatological Hospital, Fudan University, Shanghai,
China
3
Department of Preventive Dentistry, Shanghai Stomatological Hospital, Fudan University, Shanghai, China
4
Department of Orthodontics, Shanghai Stomatological Hospital, Fudan University, Shanghai, China
5
Minhang Preventive Dental Clinic, Shanghai, China
*
These authors contributed equally to this work.

ABSTRACT
Background. Epidemiological data on malocclusion among Chinese children are
scant. The aim of this study was to provide detailed information on the prevalence
of malocclusion in early mixed dentition children in Shanghai, China.
Methods. A cross-sectional survey was conducted from September 2016 to April 2017,
and 2,810 children aged 7- to 9- years were selected from 10 primary schools by cluster
random sampling. Several occlusal parameters, including Angle molar relationship,
overjet, overbite, open bite, anterior and posterior crossbite, midline displacement,
scissors bite, and teeth crowding and spacing, were clinically registered by five calibrated
orthodontic dentists.
Results. We found that 79.4% children presented one or more occlusal anomalies.
Angle Class I, Class II and Class III molar relationship were recorded in 42.3%, 50.9%
and 5.9% of the sample, respectively. The proportion of Class III increased from 5.0%
at age 7 to 7.8% at age 9. In the sagittal plane, increased overjet >3 mm was observed
in 40.8% subjects, while the prevalence of severe overjet (>8 mm), anterior edge-to-
Submitted 31 July 2018 edge (zero overjet) and anterior crossbite were 5.2%, 8.1% and 10.5%, respectively.
Accepted 15 February 2019 Vertically, deep overbite >2/3 overlap was found in 6.2% of the children and open bite
Published 2 April 2019
in 4.3%. Boys exhibited a higher rate of overbite than girls. For the transversal occlusal
Corresponding author anomalies, 36.1% of the children had a midline displacement, which was followed by
Li Chen, [email protected]
posterior crossbite (2.6%) and scissors bite (1.0%). Teeth space discrepancies were also
Academic editor common anomalies and anterior crowding (>2 mm) affecting 28.4% of the children,
Anne Marie Kuijpers-Jagtman
while anterior spacing (>4 mm) affecting 9.5%. Girls showed a higher prevalence of
Additional Information and anterior crowding and a lower frequency of teeth spacing than boys.
Declarations can be found on
page 10
Conclusions. Our study demonstrated that malocclusion is prevalent among children
in the early mixed dentition, and more health resources should be warranted to meet
DOI 10.7717/peerj.6630
the challenge of prevention or early intervention of malocclusion.
Copyright
2019 Yu et al.
Subjects Dentistry, Epidemiology, Pediatrics
Distributed under
Creative Commons CC-BY 4.0 Keywords Malocclusion, Early mixed dentition, Prevalence, Angle classification, Overjet, Open
bite, Crossbite, Crowding, Spacing
OPEN ACCESS

How to cite this article Yu X, Zhang H, Sun L, Pan J, Liu Y, Chen L. 2019. Prevalence of malocclusion and occlusal traits in the early
mixed dentition in Shanghai, China. PeerJ 7:e6630 http://doi.org/10.7717/peerj.6630
 INTRODUCTION
Malocclusion is one of the most common oral disorders among children, and it affects
not only the oral masticatory function but also the craniofacial development and facial
appearance. Children with certain malocclusion traits appear to have more problems
related to psychology and social interactions, and even their quality of life suffers when
they reach adulthood (Martins-Junior, Marques & Ramos-Jorge, 2012; Nguyen et al., 1999;
Stenvik, Espeland & Berg, 2011). For this reason, malocclusion is regarded as an emerging
public health issue.
The mixed dentition is an important developmental stage to the undisturbed occlusal
relationship. The eruption of the first permanent molar plays a critical role in maintaining
the interarch space and the sagittal occlusal relationship. Several longitudinal observations
have revealed that a substantial number of malocclusions occur during this period
(Dimberg et al., 2015; Dimberg et al., 2013; Gois et al., 2012), and the accumulated evidence
has indicated that early intervention starting from the mixed dentition would benefit
the youngsters with Class III malocclusion, crossbite, crowding and posterior crossbite
(Gianelly, 2002; Keski-Nisula et al., 2008; Lippold et al., 2013; Mitani, 2002).
Epidemiological information is essential for developing strategies and plans to promote
oral health. In China, national or local surveys on dental caries and periodontitis have
been carried out regularly (Li & Wang, 2014; Zhou et al., 2018). However, there is still
insufficient information on the prevalence of malocclusions. Recently, we made an effort to
investigate the malocclusion status of Shanghai preschool children and an extraordinarily
high prevalence, 83.9%, was found (Zhou et al., 2017). In the current study, another
cross-sectional survey was carried out to assess the prevalence of malocclusion and the
distribution of occlusal traits among school children at the stage of early mixed dentition
in Shanghai.

MATERIALS AND METHODS

Study sample
For the period of September 2016 to April 2017, a cluster random sampling was applied in
this study. In brief, we chose five administrative districts in Shanghai city: three of them in
the urban area (Hongkou, Putuo, and Jing’an districts) and two in the suburbs (Pudong
and Minhang districts). Then, two primary schools in each district were randomly selected,
and the students with the following characteristics were identified as candidates of this
survey: (1) aged 7–9 years; (2) without a history of orthodontic treatment; (3) without
craniofacial diseases; and (4) consensual participation of the children and their parents. In
all, 2,810 children, including 1,479 boys and 1,331 girls, were recruited.
The protocol of this study was approved by the Ethics Committee of Shanghai
Stomatological Hospital, Fudan University (Approval Number: 2015-0012). Written
informed consent was signed by the parents of all the children who participated in the
survey.

Yu et al. (2019), PeerJ, DOI 10.7717/peerj.6630 2/15

 Table 1 Definition of occlusal traits along with the criteria of malocclusion.

Occlusal traits Definition Malocclusion

1. Sagittal anomalies
1.1 First permanent molars Class I, the mesiobuccal cusp of the maxillary first Class III
permanent molar occludes with the mesiobuccal groove of
the mandibular first permanent molar (normal relation),
or up to or equal to 1/2 cusp width post-normal or pre-
normal relation; Class II (distal), more than 1/2 cusp width
post-normal relation; Class III (mesial), more than 1/2 cusp
width pre-normal relation.
1.2 Increased overjet Distance of the most protruded maxillary incisor to the >3 mm
corresponding mandibular incisor: 0 mm, edge-to-edge
(upper incisal edges touch lower edges when biting); >0
mm, ≤3 mm, normal; >3 mm, ≤5 mm, mild; >5 mm, ≤8
mm, moderate; >8 mm, severe
1.3 Anterior crossbite One or more of the maxillary incisors/canine occluded Present
lingually to the mandibular incisors/canine.
2. Vertical anomalies
2.1 Deep overbite Coverage of the mandibular incisors by most of the >2/3
maxillary incisors: >0, ≤1/3, normal; >1/3, ≤1/2, mild;
>1/2, ≤2/3, moderate; >2/3, severe
2.2 Open bite Negative vertically overlapping between the maxillary and >0 mm
the mandibular incisors: >0, ≤3 mm, mild; >3 mm, ≤5
mm, moderate; >5 mm, severe
3. Transversal anomalies
3.1 Midline displacement Mandibular midline deviated 2 mm or more to the Present
maxillary midline
3.2 Posterior crossbite One or more of the maxillary molars occluded lingually to Present
the mandibular molars
3.3 Scissors bite Maxillary molars occluded to the buccal surfaces of the Present
corresponding mandibular molars, and/or mandibular
molars occluded to the lingual surfaces the corresponding
maxillary molars
4. Space discrepancies
4.1 Crowding (anterior, posterior; maxillary, >0 mm, ≤2 mm, mild; >2 mm, ≤4 mm, moderate; >4 mm, >2 mm
mandibular) severe
4.2 Anterior spacing (maxillary, mandibular) >0 mm, ≤2 mm, mild; >2 mm, ≤4 mm, moderate; >4 mm, >4 mm
severe

Oral examination
The oral examination was carried out by five calibrated orthodontic dentists. The children
were examined at schools, using portable lighting and disposable mouth mirrors. Sagittal
molar relationships by Angle classification, degree of overjet and overbite, anterior and
posterior crossbite, and teeth crowding and spacing were recorded (Table 1).
The children who presented one or more of the following indications were registered
as malocclusion: Angle Class III, increased overjet (>3 mm), anterior crossbite, anterior
edge-to-edge, deep overbite (>2/3 overlap), open bite, midline displacement, posterior
crossbite, posterior edge-to-edge, scissors bite, anterior or posterior crowding (>2 mm),
and anterior spacing (>4 mm).

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 Table 2 Prevalence of malocclusion in 7–9-year-old children in Shanghai.

n Normal occlusion Malocclusion P

n % n %
Age (years) 0.354a
7 937 190 20.3 747 79.7
8 1,217 241 19.8 976 80.2
9 656 148 25.6 508 77.4
Gender 0.624a
Boys 1,479 310 21.0 1,169 79.0
Girls 1,331 269 20.2 1,062 79.8
Total 2,810 579 20.6 2,231 79.4
Notes.
a
Chi-squared test.

Reliability of examinations
Twenty subjects were evaluated by the five examiners independently of each other. One of
the examiners was an orthodontist with more than fifteen years’ clinic experience, and the
other four examiners compared their results to the senior orthodontist’s data respectively.
Inter-examiner reliability was determined by calculating Cohen’s kappa coefficient, and
the values were >0.68.

Statistical analysis
The rates of occlusal characteristics and malocclusion were reported by age and gender.
The chi-squared test and Fisher’s exact probability method were applied to determine the
statistical associations between the independent variables and the malocclusion variable.
Cohen’s kappa value was used to measure the agreement among examiners. The data were
input using the Epidata software and analyzed using SPSS Statistics 22 (IBM, Armonk, NY,
USA). The level of significance was set at p < .05.

RESULTS
The overall prevalence of malocclusion among school children aged 7–9 years in Shanghai
was 79.4% (2231/2810), and only 20.6% of them had normal occlusion (Table 2). The boys
had a very similar rate of malocclusion to that of the girls. No significant difference was
observed between age groups (p > .05).
The distribution of the sagittal occlusal features among the children in Shanghai is
shown in Table 3. The relationship of the first molars was classified according to the Angle
classification; 42.3% children showed a Class I relationship, 50.9% children were Class II,
and 5.9% were Class III. An increasing trend in the rate of Angle Class III with age was
observed, from 5.0% at age 7 to 7.8% at age 9. The increased overjet was prevalent (40.8%),
and most of the cases were mild or moderate, but 5.2% of the children were found to have
a severe overjet. Approximately one-tenth of the children had an anterior crossbite.
Table 4 depicts the vertical and transversal occlusal anomalies. The probability of the
deep overbite of the anterior teeth was 43.8% and that of severe overbite was 6.2%. Boys
were more prone to deep overbite than girls (p = .003). The rate of open bite of anterior

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 Table 3 Composition and prevalence of sagittal occlusal characteristic in 7–9-years-old children in Shanghai.

Sagittal occlusal characteristic Age (years) P Sex P Total

7 8 9 Boys Girls n %
c d
First permanent molar 0.017 0.361
Normal (Class I) 404 488 298 647 543 1,190 42.3
(43.1%) (40.1%) (45.4%) (43.7%) (40.8%)
Distal (Class II) 474 650 306 734 696 1,430 50.9
(50.6%) (53.4%) (46.6%) (49.6%) (52.3%)
Mesial (Class III) 47 68 51 86 80 166 5.9
(5.0%) (5.6%) (7.8%) (5.8%) (6.0%)
Mixeda 3 4 0 2 5 7 0.2
(0.3%) (0.3%) (0.0%) (0.1%) (0.4%)
Lost/Not eruptedb 9 7 1 10 7 17 0.6
(1.0%) (0.6%) (0.2%) (0.7%) (0.5%)
Increased overjet 0.049d 0.413d
Edge to edge 80 97 52 128 101 229 8.1
(8.5%) (8.0%) (7.9%) (8.7%) (7.6%)
Normal (>0 mm, ≤3 mm) 486 604 345 751 684 1,435 51.1
(51.9%) (49.6%) (52.6%) (50.8%) (51.4%)
Mild (>3 mm, ≤5 mm) 238 275 148 340 321 661 23.5
(25.4%) (22.6%) (22.6%) (23.0%) (24.1%)
Moderate (>5 mm, ≤8 mm) 99 161 80 190 150 340 12.1
(10.6%) (13.2%) (12.2%) (12.8%) (11.3%)
Severe (>8 mm) 34 80 31 70 75 145 5.2
(3.6%) (6.6%) (4.7%) (4.7%) (5.6%)
Anterior crossbite 0.894d 0.876d
Absent 836 1,093 586 1,325 1,190 2,515 89.5
(89.2%) (89.8%) (89.3%) (89.6%) (89.4%)
Present 101 124 70 154 141 295 10.5
(10.8%) (10.2%) (10.7%) (10.4%) (10.6%)
Notes.
a
Child with Class II first molar relation on one side and Class III on the other side.
b
One or more first molars were missing or did not fully erupt.
c
Fisher’s exact test.
d
Chi-squared test.

teeth was 4.24%; it decreased with age, from 4.9% at age 7 to 2.7% at age 9. With respect to
transversal anomalies, 36.1% of the children were found to have a midline displacement,
and 2.6% had posterior crossbite. The prevalence of a scissors bite was relatively low (0.9%),
but it increased with age.
Teeth crowding and spacing were prevalent among the children (Table 5). The prevalence
of anterior crowding of >2 mm of the maxillary or mandibular teeth was 13.3% and 22.5%,
respectively. In all, 28.4% of the children presented anterior crowding. Posterior crowding
was less common, and only 0.2% of the subjects were found to have maxillary posterior
crowding of >2 mm, and 1.0% was mandibular posterior. The rate of anterior spacing of
>4 mm of the maxillary teeth was 8.0%, and that of the mandibular teeth was 3.0%. An
increasing trend with age was observed for the rate of crowding of the upper anterior teeth,

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 Table 4 Composition and prevalence of vertical and transverse anomalies in 7–9-years-old children in Shanghai.

Age (years) P Sex P Total

7 8 9 Boys Girls n %
a a
Deep overbite 0.127 0.003
None 94 133 60 158 129 287 10.2
(10.0%) (10.9%) (9.1%) (10.7%) (9.7%)
Normal (>0, ≤1/3) 451 535 307 629 664 1,293 46.0
(48.1%) (44.0%) (46.8%) (42.5%) (49.9%)
Mild (>1/3, ≤1/2) 216 294 137 366 281 647 23.0
(23.1%) (24.2%) (20.9%) (24.7%) (21.1%)
Moderate (>1/2, ≤2/3) 117 178 115 226 184 410 14.6
(12.5%) (14.6%) (17.5%) (15.3%) (13.8%)
Severe (>2/3) 59 77 37 100 73 173 6.2
(6.3%) (6.3%) (5.6%) (6.8%) (5.5%)
Open bite 0.225b 0.222b
None 890 1,162 638 1,420 1,270 2,690 95.7
(95.0%) (95.5%) (97.3%) (96.0%) (95.4%)
Mild (>0, ≤3 mm) 41 52 17 56 54 110 3.9
(4.4%) (4.3%) (2.6%) (3.8%) (4.1%)
Moderate (>3, ≤5 mm) 5 3 1 2 7 9 0.3
(0.5%) (0.2%) (0.2%) (0.1%) (0.5%)
Severe (>5 mm) 1 0 0 1 0 1 0.04
(0.1%) (0.0%) (0.0%) (0.1%) (0.0%)
Midline displacement 326 469 219 0.052a 544 470 0.418a 1,014 36.1
(34.8%) (38.5%) (33.4%) (36.8%) (35.3%)
Posterior crossbite 22 29 23(3.5%) 0.280a 41 33 0.628a 74 2.6
(2.3%) (2.4%) (2.8%) (2.5%)
Scissors bite 2 11 12 0.003b 12 13 0.641a 25 0.9
(0.2%) (0.9%) (1.8%) (0.8%) (1.0%)
Notes.
a
Chi-squared test.
b
Fisher’s exact test.

and the boys’ probability of anterior crowding, either of the maxillary or of the mandibular
teeth, was lower than that of the girls’ (p < .001).

DISCUSSION
The prevalence of malocclusion in different populations ranges from 21% to 90%
(Grippaudo et al., 2013; Perillo et al., 2010; Perinetti et al., 2008; Shalish et al., 2013;
Thilander et al., 2001), and this huge variation may largely be attributed to the discrepancies
in the definitions of malocclusion and the methodologies applied. We found that the
prevalence of malocclusion in early mixed dentition in Shanghai was as high as 79.4%, which
was considerably higher than the rate of 71.2% among children with mixed dentition in a
national survey in 2000 (Fu et al., 2002). This result was similar to the rate of malocclusion
in the deciduous dentition, i.e., 83.9%, in the Shanghai area (Zhou et al., 2017). Our
findings confirmed that malocclusion was one of the most common health problems in
children and adolescents.

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 Table 5 Composition and prevalence of space discrepancies in 7–9-years-old children in Shanghai.

Age (years) P Sex P Total

7 8 9 Boys Girls n %
a a
Maxillary anterior crowding <0.001 <0.001
None 631 727 366 973 751 1,724 61.4
(67.3%) (59.7%) (55.8%) (65.8%) (56.4%)
>0, ≤2 mm 201 311 199 341 370 711 25.3
(21.5%) (25.6%) (30.3%) (23.1%) (27.8%)
>2, ≤4 mm 92 144 68 127 177 304 10.8
(9.8%) (11.8%) (10.4%) (8.6%) (13.3%)
>4 mm 13 35 23 38 33 71 2.5
(1.4%) (2.9%) (3.5%) (2.6%) (2.5%)
Maxillary posterior crowding 0.011b 0.364b
None 920 1,193 655 1,462 1,306 2,768 98.5
(98.2%) (98.0%) (99.8%) (98.9%) (98.1%)
>0, ≤2 mm 14 21 1 14 22 36 1.3
(1.5%) (1.7%) (0.2%) (0.9%) (1.7%)
>2, ≤4 mm 2 2 0 2 2 4 0.1
(0.2%) (0.2%) (0.0%) (0.1%) (0.2%)
>4 mm 1 1 0 1 1 2 0.1
(0.1%) (0.1%) (0.0%) (0.1%) (0.1%)
Mandibular anterior crowding 0.006a <0.001a
None 373 583 313 736 533 1,269 45.2
(39.8%) (47.9%) (47.7%) (49.8%) (40.0%)
>0, ≤2 mm 330 367 212 444 465 909 32.3
(35.2%) (30.2%) (32.3%) (30.0%) (34.9%)
>2, ≤4 mm 184 204 99 227 260 487 17.3
(19.6%) (16.8%) (15.1%) (15.3%) (19.5%)
>4 mm 50 63 32 72 73 145 5.2
(5.3%) (5.2%) (4.9%) (4.9%) (5.5%)
Mandibular posterior crowding 0.141b 0.991a
None 917 1,191 648 1,450 1,306 2,756 98.1
(97.9%) (97.9%) (98.8%) (98.0%) (98.1%)
>0, ≤2 mm 11 15 1 15 12 27 1.0
(1.2%) (1.2%) (0.2%) (1.0%) (0.9%)
>2, ≤4 mm 7 9 7 12 11 23 0.8
(0.7%) (0.7%) (1.1%) (0.8%) (0.8%)
>4 mm 2 2 0 (0) 2 2 4 0.1
(0.2%) (0.2%) (0.1%) (0.2%)
Maxillary anterior spacing <0.001a <0.001a
None 487 760 434 841 840 1,681 59.8
(52.0%) (62.4%) (66.2%) (56.9%) (63.1%)
>0, ≤2 mm 244 277 128 356 293 649 23.1
(26.0%) (22.8%) (19.5%) (24.1%) (22.0%)
>2, ≤4 mm 115 102 39 137 119 256 9.1
(12.3%) (8.4%) (5.9%) (9.3%) (8.9%)
(continued on next page)

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Table 5 (continued)
Age (years) P Sex P Total
7 8 9 Boys Girls n %
>4 mm 91 78 55 145 79 224 8.0
(9.7%) (6.4%) (8.4%) (9.8%) (5.9%)
Mandibular anterior spacing 0.116a 0.081a
None 734 948 523 1,136 1,069 2,205 78.5
(78.3%) (77.9%) (79.7%) (76.8%) (80.3%)
>0, ≤2 mm 129 183 82 216 178 394 14.0
(13.8%) (15.0%) (12.5%) (14.6%) (13.4%)
>2, ≤4 mm 51 52 23 75 51 126 4.5
(5.4%) (4.3%) (3.5%) (5.1%) (3.8%)
>4 mm 23 34 28 52 33 85 3.0
(2.5%) (2.8%) (4.3%) (3.5%) (2.5%)
Notes.
a
Chi-squared test.
b
Fisher exact test.

Deep overbite (>1/3 overlap, prevalence 43.8%) and increased overjet (>3 mm,
prevalence 40.8%) were the two most common types of occlusion abnormalities in
Shanghai schoolchildren. The high rates of overbite and overjet were also reported in
Nigeria (deep overbite: 31.7% and increased overjet: 44.6%) (DaCosta et al., 2016) and in
China’s western city Xi’an (deep overbite 37.6% and increased overjet 35.0%) (Zhou et al.,
2016). Nevertheless, compared to the fact that 63.7% of the preschool children were found
to have deep overbite in Shanghai (Zhou et al., 2017), it was less frequent in the age group
considered in this study. This decline could be partly explained by the self-correction of
deep overbite during dental development (Dimberg et al., 2015). The increased overjet (>3
mm) occurred more frequently in the early mixed dentition (43.8%) than in the primary
stage (33.9%) (Zhou et al., 2017). However, in terms of severe increased overjet (>8 mm),
the change was substantial: 0.9% for primary and 5.2% for mixed dentition. This change
may increase the risk of oral trauma (Nguyen et al., 1999).
Anterior crowding and anterior crossbite were another two high-incidence
malocclusions observed in this study. In contrast to deep overbite, crowding and crossbite
are less likely to be self-corrected without any intervention or treatment. Anterior crowding
of >2 mm was recorded in 28.4% of the subjects, considerably more frequent than the
proportion in primary dentition in the city (Zhou et al., 2017). Moreover, the crowding
problem might be worse in the permanent dentition stage, as the arch length decreased
during the transition from the mixed to the permanent dentition (Gianelly, 2002). It was
noteworthy that anterior crowding was more prevalent in the mandible (22.5%) than
maxilla (13.3%) in Shanghai children, which was consistent in what was found among
children in the early mixed dentition in Germany (Tausche, Luck & Harzer, 2004) and
adolescents in the permanent dentition in Japan (Komazaki et al., 2012). However, in Iran
and Turkey, adolescents had more crowding in the maxilla than mandible (Borzabadi-
Farahani, Borzabadi-Farahani & Eslamipour, 2009; Gelgor, Karaman & Ercan, 2007).
The prevalence of anterior crossbite in Shanghai children was comparable to that in
Israeli (9.5%) (Shalish et al., 2013), German (7.7%) (Tausche, Luck & Harzer, 2004), and

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 Iranian (8.4%) (Borzabadi-Farahani, Borzabadi-Farahani & Eslamipour, 2009) children.
Nevertheless, only 2.6% of the children had a posterior crossbite, which was relatively
less frequent comparing the rates in Canada (15%) (Karaiskos et al., 2005), Brazil (13.3%)
(Almeida et al., 2011) and Israel (23.3%) (Shalish et al., 2013). Several studies have pointed
out that Chinese adults have a higher prevalence of Angle Class III malocclusion than the
other racial groups (Lew, Foong & Loh, 1993; Soh, Sandham & Chan, 2005; Woon, 1988);
however, we found that this rate was acceptable in Shanghai children, even though it was
slightly lower in children from other Asian countries (Borzabadi-Farahani, Borzabadi-
Farahani & Eslamipour, 2009; Komazaki et al., 2012). We found about 50 percent of the
children had an Angle Class II molar relationship, and the rate was much higher than
those reported in Germany (28%) (Tausche, Luck & Harzer, 2004), Brazil (21.4%) (Dias
& Gleiser, 2009), Israel (29.9%) (Shalish et al., 2013) and Sweden (28%) (Dimberg et al.,
2013). A high prevalence of Angle Class II, namely 38.2%, was also reported among 12 to
15-year-old adolescents in Japan (Komazaki et al., 2012), and it seemed that East Asians
were more prone to have Angle Class II.
Although there was no difference of overall prevalence of malocclusion between boys and
girls, several sexual dimorphisms were identified in the current study. It seemed that boys
were more likely to have an overbite than girls, and this finding was supported by previous
studies in Germany, France, Turkey and Brazil (Dias & Gleiser, 2009; Gelgor, Karaman &
Ercan, 2007; Lux et al., 2009; Souames et al., 2006). Nevertheless, anterior crowding was
more prevalent among girls than boys, which was consistent with what was found in Japan
and Colombia (Komazaki et al., 2012; Thilander et al., 2001). These dimorphisms might be
explained by the differences in skeletal maturity and/or eruption of permanent teeth (Lux
et al., 2009).
Despite the reported benefit of early intervention of malocclusion (Dimberg et al., 2013;
Keski-Nisula et al., 2008; Proffit, 2006), the high prevalence of malocclusion did not mean
that most children were subjected to orthodontic treatment. Since these children were in
the ‘‘ugly duckling’’ stage, and they probably suffered transient malocclusions, and some of
them, such as maxillary midline diastema, increased overjet, deep overbite, crowding and
even Angle Class II molar relationship, might be spontaneously corrected (Dimberg et al.,
2015; Huang & Creath, 1995; Kapur et al., 2018). On the other hand, treatment priorities
may vary depending on the severity of malocclusions. Therefore, many investigators have
considered the orthodontic treatment need indices such as the Index of Orthodontic
Treatment Need (IOTN) in epidemiological studies (DaCosta et al., 2016; Komazaki et al.,
2012; Shalish et al., 2013; Steinmassl et al., 2017; Tausche, Luck & Harzer, 2004; Thilander
et al., 2001). Even though the assessment of the orthodontic treatment need was not the
major aim of the current survey, we attempted to obtain a rough estimate of this need
on the basis of the criteria of IOTN’s Grade 4 and Grade 5 and found that 26.2% of the
children exhibited one or more of the following conditions (Table S1): Angle Class III,
increased overjet >8 mm, anterior crossbite, open bite >3 mm, posterior crossbite, scissors
bite, and anterior or posterior crowding >4 mm. This rate was consistent with that in

Yu et al. (2019), PeerJ, DOI 10.7717/peerj.6630 9/15

 the Germans (26.2%) (Tausche, Luck & Harzer, 2004), the Iranians (23%) (Borzabadi-
Farahani, Borzabadi-Farahani & Eslamipour, 2009), and the Austrians (30.6%) (Steinmassl
et al., 2017).
A strict cluster random sampling was conducted, and a good representation was obtained
in this study. Since this survey was school-based, it was infeasible to obtain the treatment
records from the children who had a history of orthodontic intervention, and we excluded
them because we did not know their original occlusal traits which had already been changed.
Although many investigators did so in previous epidemiological studies (Komazaki et al.,
2012; Lagana et al., 2013; Souames et al., 2006; Thilander et al., 2001), it should be kept in
mind that this exclusion may introduce some representativeness bias. However, to the
best of our knowledge, very few children under the age of 10 years appeal to orthodontists
for malocclusion in Shanghai, the effects of the exclusion may be limited. Actually, in
the current study, no more than one percent of the subjects had received orthodontic
treatment, which was less than the rate reported in French children (Souames et al., 2006).
A large number of young people meet the criteria for early orthodontic treatment, and
this is a huge challenge for our health system. Besides early treatment, establishing effective
policies to prevent the occurrence of malocclusion may be another choice. Multiple
factors, including genetic, environmental, and social-behavioral factors, play a role in the
development of malocclusion (Grippaudo et al., 2016; Lagana et al., 2013). Some feeding
habits and oral habits are believed to be important causes of malocclusion, and sucking
habits are associated with anterior open bite and posterior crossbite (Agarwal et al., 2014;
Boronat-Catala et al., 2017; Gungor, Taner & Kaygisiz, 2016). Therefore, attention needs to
be paid to malocclusion disorders, and early health education and behavior intervention
may contribute to a reduction of the burden of malocclusion.

CONCLUSIONS
Our cross-sectional study demonstrated that 79.4% of the children in the stage of mixed
dentition had one or more malocclusion traits. For the prevention and intervention of
malocclusion, substantial resources and efforts are warranted from orthodontists, health
policy makers, communities, and, of course, families.

ACKNOWLEDGEMENTS
The authors would like to express their sincere gratitude to all the workers of the
five Preventive Dental Clinics in the Hongkou, Putuo, Jing’an, Pudong, and Minhang
districts for supporting this study. We thank LetPub for its linguistic assistance during the
preparation of this manuscript.

ADDITIONAL INFORMATION AND DECLARATIONS

Funding
This study was supported by Projects of Development and Application of Suitable Health
Technology of Shanghai Hospital Development Center (SHDC) (No. SHDC12014226),

Yu et al. (2019), PeerJ, DOI 10.7717/peerj.6630 10/15

 Three Year Action Plan for Strengthening Public Health System in Shanghai (No. GWIV-
12), Projects of Shanghai Municipal Commission of Health and Family Planning (No.
2016ZB0102-01) and Project of Characteristic Medical Specialty in Minhang Shanghai
(No. 2017MWTZ20). The funders had no role in study design, data collection and analysis,
decision to publish, or preparation of the manuscript.

Grant Disclosures
The following grant information was disclosed by the authors:
Projects of Development and Application of Suitable Health Technology of Shanghai
Hospital Development Center (SHDC): SHDC12014226.
Strengthening Public Health System in Shanghai: GWIV-12.
Projects of Shanghai Municipal Commission of Health and Family Planning: 2016ZB0102-
01.
Project of Characteristic Medical Specialty in Minhang Shanghai: 2017MWTZ20.

Competing Interests
The authors declare there are no competing interests.

Author Contributions
• Xin Yu performed the experiments, prepared figures and/or tables, authored or reviewed
drafts of the paper, approved the final draft.
• Hao Zhang performed the experiments, analyzed the data, prepared figures and/or
tables, authored or reviewed drafts of the paper, approved the final draft.
• Liangyan Sun and Jie Pan performed the experiments, approved the final draft.
• Yuehua Liu conceived and designed the experiments, authored or reviewed drafts of the
paper, approved the final draft.
• Li Chen conceived and designed the experiments, performed the experiments, authored
or reviewed drafts of the paper, approved the final draft.

Human Ethics
The following information was supplied relating to ethical approvals (i.e., approving body
and any reference numbers):
This study was approved by the Ethics Committee of Shanghai Stomatological Hospital,
Fudan University (2015-0012).

Data Availability
The following information was supplied regarding data availability:
The raw data is available in the Supplemental Files.

Supplemental Information
Supplemental information for this article can be found online at http://dx.doi.org/10.7717/
peerj.6630#supplemental-information.

Yu et al. (2019), PeerJ, DOI 10.7717/peerj.6630 11/15

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